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IV <br /> \ APPLICATION FOR-,SANITATION PERMIT Permit No. ........ <br /> 1.�.r� <br /> {Completein Duplicate) <br /> , j <br /> Date Issued .------ �Sl�' <br /> Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with;County Ordinance No, <br /> 549. R <br /> r { <br /> JOB ADDRESS AND LOCATIONG�� - - `=-------------------9-- ------ "�-t---------------- <br /> -4- <br /> Owner's Name---U--- ---------- --------------- --- ---------------- ------ --------------- Phone_---------------------------•---•4 <br /> w { <br /> Address.------- ^-- �----------------------------- ---------------------------------------------. ......-------------- <br /> Contractor's Name-- ------------• -- -- ------ •----••-----•--------------- Phone-------------------�II��... ' <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trail'e'r Court ❑ Motel ❑ Other <br /> II 1 q�r <br /> Number of living units: --___-_ umber of bedrooms -------. Number of baths . Lot size ...1- ... .1 -------------------- --._ <br /> Water Supply: Public system [C _ <br /> Community system ❑ Private ❑ Depth to Water Table _------- ff. I <br /> Character of soil to a depth of 3 feet: Sand E] Gravel Sandy Loam Clay Loam ❑ Clay ❑ Adobe�ardpan E]Previous Application Made: Yes E] No New Construction:: Yes [dNNo ❑ ti <br /> - i <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted 'f ubhc seliver is available within 200 11feet1) <br /> Septic Tank: Distance from nearest wel-- _ Qistanee from rfountion.l..0.- <br /> ----------- t riai_1 <br /> No. of compartments...... ..... -------------Size..s .f ----------Liquid Oepth.. - _--------------Capacity.." <br /> �f <br /> Disposal Field: Distance from nearest well.:. Qistance from faundationlQ ....""" Distance to nearest lot ii _______`_---_zZrt/, <br /> Number of lines-------- -----..Length of each line--------------- - Width of french...... _�_�f 1 <br /> Type of filter materi "'"".�_�__�__/. epth"f filter material----------- ----- Total length---_-----.. -"O _ <br /> Seepage Pit: Distance to nearest well-----------------"----Dista Distance from foundation.------ -_.-......_.Distance to nearest lot line.-------.---.--_ <br /> ❑ Number of P ------Lining material-----------------------Size: Diameter----•----------------- Depth----------------------------• - <br /> pits. ' <br /> Cesspool.• Distance from nearest well-----------------Distance from foundation....................Lining material-_..------.----------_-----..-_.--.. <br /> k -❑ Size:-Diameter-------- ------------------------------Deth- ------ =_ - _- -Liquid-Ca acit. - -- a <br /> N f�'Privy: -Distance from nearest well ------------------------------.-----------------Distance from nearest building------------------------------------------ <br /> 1771 Distance to nearest lot line----------------------- -----•---------------- --------------------------------- ------------------------------------------------------------ <br /> . <br /> mod mg x,d or <br /> P - -repairing (des ib ... <br /> - <br /> V -------------------------•--- <br /> ) <br /> ---------------•----------------------•---••-----------------•--•--•--•----••-•---••-•----•-----------.------•------------:-------------------------.----•------------- <br /> ------------ <br /> --------­---------- ------------------------------------------------------------•-------------•---------------------•--- ------------------------------------•-------•-----• <br /> ------ --------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, State laws, and rules and regulations of a San Joaquin Local Health District. # <br /> (Signed)------- L/ior' r -- ------- (Owner and/or Contractor) l <br /> By:------------------- ------ - --- --- ----------- <br /> ----------- ------------------------(Title)-------------------------------------------=------------------ <br /> (Plot plan, showing size of lot, location of system i r lation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- ............................... DATE.�---------•-------------------------- <br /> ----------------- <br /> } <br /> REVIEWEDBY------------------------------- - ----------------- ---------------- --- ----------------------------------------- DATE-- ------ ------ <br /> BUILDING <br /> ----BUILDING PERMIT ISSUED---------------------------------------------- ------ ------------------------------------------------ DATE-------rs�r~-------------------------------------------------- <br /> Alterations and/or recommendations----------- ---------------- ------------------------------- ----------------------- •-•-----• =....:_ <br /> ---•---•-"-----------------••-----------------------•--------------------------------------------------------------------•----------------•------------••--•------------------------••---.................................... <br /> ------------------------------------- ----- -------------------•--------- --------- --•------------ -------------•---•--•-------------------------------------'------- <br /> -- --------------- <br /> FINAL INSPECTION BY•.... Date- � ��l <br /> ---------------- ------------- ------------ -- ------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 014 North "C" Street F. <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> 1 <br /> rn--9-2m 145446 ATwnoD 1Z-54 <br />